acceptance of a predetermined time of death are less likely to seek care (Hoang and Erickson, 1985; Uba, 1992).

Language and other communication difficulties between families and providers can increase dissatisfaction with care and decrease the likelihood that the family will seek care again (Malach and Segal, 1990; Uba, 1992). Spanish-speaking asthmatics whose clinicians did not speak Spanish were found to be less likely to come to follow-up appointments, less likely to take medications appropriately, and more likely to use an emergency department (Manson, 1988).

Changes in the health care system can reduce the racial, ethnic, and cultural differences in the patterns of care. For example, after barriers to care were reduced through 24-hour availability of care and limiting the waiting time for appointments, a Baltimore study found that the use of health care became more comparable for black and white children (Orr et al., 1984, 1988). Similarly, when language and income barriers were minimized, urban Mexican American and white elementary-school children no longer differed in their use of health care services (Gilman and Bruhn, 1981).

There is growing recognition of the importance of including culturally competent health care as a measure of health care quality (IOM, 1997; Lavizzo-Mourey and Mackenzie, 1996). HEDIS 3.0 (Healthplan Employer Data and Information Set), the most widely used set of performance measures for managed care organizations, includes ''availability of language and interpretation services" as a measure of access to care. Many professional organizations are developing training programs to increase providers' ability to meet the needs of patients from diverse backgrounds (AAPCHO, 1994; AMA, 1994; Tirado, 1995).

Organizational and Systems Barriers to Access

Many aspects of the health care system also can decrease children's access to care. Waiting time for available appointments, lack of 24-hour availability of physicians, travel time, waiting room time, and actual processing time for patients can present significant barriers to seeking and receiving care (Fossett et al., 1992; Riportella-Muller et al., 1996).

For families living in underserved urban or rural areas, access to qualified providers can be even more difficult because provider shortages limit the number of available appointments (Fossett et al., 1992; St. Peter et al., 1992). For example, a study in Chicago found that pediatricians in inner-city residential areas cared for almost twice as many children as pediatricians located in the most prosperous areas (Fossett et al., 1992).

We tend to look at this health insurance or access issue as the end product. It really isn't. The end product is really better outcomes for kids. So health insurance becomes one piece of a broader social and public health safety net that we ought to be thinking about for kids.

Patrick Chaulk

Annie E. Casey Foundation, Baltimore, MD

Public Workshop, June 2, 1997

As discussed throughout this report, managed care is changing the delivery of American health care. There are relatively few studies of the impact of managed care on children's access to care, and the results are decidedly mixed. For example, there is some evidence that children are more likely to receive preventive services when they are enrolled in managed care plans than when they have traditional indemnity insurance (Carey et al., 1990; Szilagyi et al., 1990). However, studies in the early 1990s



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